Clinical Studies

In cardiac surgery, head-down and head-up positions are used to control cardiac filling pressure and for cardiac exposure. Even though benefits of head positioning are not clear, they can also bring some risks. Understanding physiological consequences of positioning can help avoiding serious adverse events and complications. In this prospective study we investigated the effect of head-down and head-up position upon systemic and cerebral haemodynamics and cerebral oxygenation and their correlation with Bispectral Index (BIS) in CABG patients under general anesthesia before surgical incision. Thirty patients were enrolled in to the study. After induction and before surgical incision blood pressure, heart rate, central venous pressure, cardiac output, stroke volume variation, BIS, cerebral oxygen saturation and middle cerebral artery blood flow rate values of the study patients were measured at neutral, head-down and head-up positions. The significance of the difference in terms of the means between the positions was studied with the repeated measures analysis of variance, while the significance of the difference in terms of the mean values was analyzed with Friedman test. Statistically significant increase were recorded in blood pressure, cardiac output, central venous pressure, cerebral blood flow rate and BIS values in the head-down position. The head-up position was associated with decrease in cardiac output. We demonstrated that both positions are safe for cerebral haemodynamics and oxygenation in ischemic heart patients. We showed that the short term head-down position can improve cardiac function, probably due to increased preload in ischemic heart patients with normal ejection fraction; however, the head-up position can be detrimental for systemic haemodynamic even for a short period.

Patient care in Intensive Care Units is characterized by high demanding tasks, which leads in daily high workload. The aim of the study is to evaluate the effect of patient’s sedation level to workload for the certain task. It also examines whether workload lowers over time, as an effect of the experience gained by the repetition of the task. NASA- TLX tool was used as workload assessments method during a complex monitoring task in an adult Intensive Care Unit environment. The latter included monitoring and recording of skin conductance variability, noise level, hemodynamic and respiratory parameters were monitored during 4 hour routine in two groups of patients. The group was defined by the sedation level (Ramsay sedation score); otherwise no major differences were spotted in their characteristics. Both raw and weighted data of the NASA-TLX tool were included in the analysis, which was performed with MS Excel 2007 (Microsoft Co, USA) and Rstudio® IDE v.0.99.903 (Rstudio Inc, Boston, MA, USA). Patients’ sedation level did not affect NASA-TLX measured workload. The former was valid both for raw values and weighted data of the subscales of the NASA-TLX tool. In the second part of the analysis where the raw values were treated as time series data, it was shown that some subscales (Ment, Phys) had a tendency towards lower values, others (e.g. Temp, Ef) had a relative stability and others (Per) increased over time. The total workload (OW) did not seem to lower over time. While the patient’s sedation level does not affect workload of the specific task, several subscales of the NASA-TLX index do reveal a tendency over time; a fact that may be used as learning curve/ experience assessment for a given task. However, further studies are needed in order to define its future utility.

Prehospital emergency medical services (PEMS) are becoming more and more sophisticated as more point-of–care advanced medical technology is available in the field. Yet, the literature around the subject is limited, as data come mainly from Northern Europe, USA, Canada and New Zealand. The aim of this analysiswas to describe time trends of PEMS activity in a region of northern Greece.Use of data retrospectively collected for PEMS usage, in the regional unit of Thessaloniki, Northern Greece from 2006 to 2015. The area of interest represents a little more than 10% of the total population of Greece.Total utilization of PEMS shows an overall l4.03% decrease over the decade; yet with an increase in the 2 last years.The mean rate of use was 69/1000 inhabitants for ambulance services and 1.5/1000 for medical interventions (MICU).

The interaction between increased Intra Abdominal Pressure (IAP) and Intrathoracic Pressure under different Positive End Expiratory Pressure (PEEP) levels is intriguing, since these two conditions coexist frequently in several clinical settings. The aim of our study was to investigate the interaction between different PEEP levels and increased IAP during laparoscopic cholecystectomy. In fifty two patients, who underwent scheduled laparoscopic cholecystectomy, cardiovascular parameters were determined by an Oesophageal Doppler Monitor device during two different time periods, before and after pneumoperitoneum, and under five conditions: (i) PEEP 0 cmH2O (ii) PEEP 5cm H2O (iii) PEEP 10cm H2O (iv) PEEP 15cm H2O and (v) in the absence of PEEP or ventilation. Cardiac output and stroke volume showed a statistically significant decrease compared to the baseline value after the application of different PEEP levels, when there was no pneumoperitoneum (p<0.05). However, both parameters increased, when PEEP and pneumoperitoneum were applied together (p<0.001). Corrected flow time, peak flow velocity in the descending thoracic aorta and mean acceleration showed similar alterations but not at all PEEP levels. Finally, αt the no PEEP or ventilation phase, the negative effects of increased IAP on the cardiocirculatory function were predominant. According to these results, application of PEEP seems to counterbalance the negative hemodynamic effects of increased IAP. Moreover, it could also be concluded that ‘ideal’ PEEP level might be the one that borders the IAP level, since the best cardiac output and stroke volume values were reported at that point.

During recent years the application of non invasive ventilation (NIV) has emerged as a central component of respiratory failure management, acute and chronic. Although the use of NIV in acute respiratory failure was initially meant to be given in critical care units, it is nowadays natural to provide it in other settings as well, provided that there are the necessary resources and expertise. NIV represents a viable alternative to endotracheal ventilation and despite most data refer to patients with chronic obstructive pulmonary disease; its indications are continuously expanding to cover more clinical scenarios. Randomized controlled studies are needed in order to provide sound evidence regarding optimal patient-ventilator interface, NIV duration and ventilation parameters in thoracic surgery patients.

This research was designed to determine the appropriateness and applicability of the Patient Bill of Rights from the viewpoint of nurses in Lorestan University of Medical Sciences to identify barriers and provide operational solutions in 2012. This is a descriptive-analytical study. Out of 440 questionnaires delivered to the nurses, 294 were completed. The data collection tool was a questionnaire related to the five domains of the Patient Bill of Rights including right to receive appropriate services, right to receive appropriate and adequate information, right to choose and decide on health services freely, respecting patient privacy and observing the principle of confidentiality, and finally right to get access to effective complaint handling system. The mean scores for appropriateness (350.16±7.23) and applicability (282.57±54.22) of the Patient Bill of Rights were high. Shortage of work force, nurses and patients’ unawareness of the major barriers of application, provision of necessities for internalization, establishment of the committee of the Patient Bill of Rights, and paying attention to nurses’ rights were the solutions proposed. Enhancing stakeholder’ s awareness and providing necessities by managers can help in the operationalization of the Bill.

Trend towards noninvasive, easy to use monitor was always a challenge. Numerous indices have been used to monitor the progress of patients on positive pressure ventilation. The present study compares different indices in a mixed larger intensive care unit (ICU) population. In a prospective observational study Arterial blood gases (ABG) analyses were obtained from 225 patients under mechanical ventilation in a polyvalent adult ICU. Values of ideal body weight (IBW), Body mass index (BMI), PAO2, PaO2/FiO2 ratio (PFr), SpO2/FiO2 ratio (SFr), SpO2/PEEP ratio (SPr), SpO2/PaCO­2 ratio (SPCr), Oxygenation index (OI) and Ventillatory ratio (VR) were calculated; and further correlation analysis was conducted. In Pressure control ventilation mode a relative strong relation between PFr and SFr and OI was found; yet further regression analysis implies that no direct replacement of PFr with SFr can be made without limitations, in clinical setting. In Volume control ventilation mode moderate relation was found between SFr and PFr. In the present study a moderate relation was found between SFr and PFr. The results agree with previous published studies; the differences among them lie in the different design of each one of them. The authors believe that- given the fact that one still considers using broadly PFr as index of oxygenation- SFr can be used safely as a surrogate for PFr only for certain disease states. Larger series are needed in order to define those patients groups and these pathophysiological conditions.

Access to appropriate and high quality health care is one of the most important ways to reduce maternal and infant mortality. This study evaluates the quality of care during childbirth, the effective factors, and promoting strategies in Lorestan province, Iran. This research is a mixed explanatory study (i.e., quantitative and qualitative). The quantitative part is descriptive-analytic. The quality of 200 care processes during childbirth was assessed in the health centers of the province. The data were gathered through the checklists prepared according to the guidelines of the Iranian Ministry of Health. Statistical analysis was performed using SPSS software. In the qualitative part, the strategies for solving the problem were assessed through interviews with service providers, maternity administrators, and senior decision-making university officials. According to our results, the levels of care quality during childbirth were intermediate in all four phases. The lowest levels of quality in the first, second and third stages were associated with Leopold's maneuver, hand washing and pulse control, respectively. Based on the interviews, the main reasons for the reduction of care quality include lack of staff’s motivation, overcrowding and shortage of nursing workforce, low attention of officials to the Department of Midwifery, and the high burden of writing in the maternity. To improve the quality of services, the authorities in Lorestan University of Medical Sciences propose strategies such as making some incentives for care promotion. Considering the quality of care during childbirth as intermediate in all four stages in the province and investigation of the reasons indicating the lack of sufficient incentive in midwives, it is recommended that strategies such as financial incentives, greater use of private sector to reduce public sector workload, quality increase and further use of in-service training to improve the quality of services be adopted.

Clinical evaluation of pupils is considered as an essential part of neurological examination. The pupillary response to light is controlled by the autonomic nervous system. Numerous factors affect pupils dynamics, like e.g. luminance, visual field area, pain, drug administration, age, the functional integrity of anatomical structures involved, e.t.c. Moreover, pupillometry card method and examination of pupil reaction with the use of a penlight is subjective to a lot of bias. Portable infrared pupillometry allows a more objective and detail evaluation of pupil’s dynamics. That’s why it has already found applications in various clinical areas, like e.g. neurology, psychology, ophthalmology, endocrinology, anesthesia, pain management, intensive care, emergency medicine. This review focuses on physiology of pupil’s dynamics and on applications of infrared pupillometry in perioperative setting.

The occurrence of intraoperative oxygenation impairment is common even in healthy individuals and will vary depending on the patient and the type of surgery. The purpose of this study was to evaluate the incidence of oxygenation impairment in patients with normal lung function and to study the safety and efficacy of three different recruitment strategies. Out of a total number of 430 patients, 150 patients developed intraoperative oxygenation impairment, which was defined as the drop of PaO2/FiO2 ratio below 300. These 150 patients were randomly assigned into four study groups according to the recruitment strategy applied. Group A (N: 38): Application of three hyperinflations of the lungs at airway pressure 40cmH2O for 10 sec, followed by an increase in PEEP from 5 to 10cmH2O. Group B (N: 38): Increase in PEEP from 5 to 10cmH2O. Group C (N: 37): Application of three hyperinflations of the lungs at airway pressure 40cmH2O for 10 sec, without any PEEP alteration and Group D (N: 37): No maneuver. Measurements were taken at the phase of oxygenation deterioration and at 5, 15, 30, 45 and 60min after applying the maneuvers and also before extubation. From a total of 430 patients 150 developed oxygenation impairment (38.4%). The median onset time of the deterioration was 30min after intubation and mechanical ventilation. In group A the PaO2/FiO2 ratio increased significantly immediately after the maneuvers and remained elevated until extubation. In group B the PaO2/FiO2 ratio presented a gradual increase to significant levels before extubation. In group C, the instant post-maneuver increase of oxygenation was not sustained until extubation. Finally in group D a gradual decrease of the PaO2/FiO2 ratio was recorded until the end of surgery. According to the results of our study, one third of patients developed intraoperative oxygenation impairment approximately half an hour after intubation. The application of three hyperinflations of the lungs at an airway pressure of 40cmH2O for 10 sec, followed by an increase in PEEP from 5 to 10cmH2O proved to be the most effective treatment of impaired oxygenation.